Development of a Quantitative Measure of Holistic Nursing Care

JHNXXX10.1177/0898010114563312Journal of Holistic NursingHolistic Nursing Care / Kinchen research-article5633122014

Practice

Development of a Quantitative Measure jhn

of Holistic Nursing Care Journal of Holistic Nursing American Holistic Nurses Association Volume XX Number X Elizabeth Kinchen, PhD, RN, AHN-BC XXXX 201X 1–9 Florida Atlantic University © The Author(s) 2014 10.1177/0898010114563312 http://jhn.sagepub.com

Holistic care has long been a defining attribute of nursing practice. From the earliest years of its formal history, nursing has favored a holistic approach in the care of patients, and such an approach has become more important over time. The expansion of nursing’s responsibility in delivering comprehensive primary care, the recognition of the importance of relationship-centered care, and the need for evidence-based legitimation of holistic nursing care and practices to insurance companies, policy-makers, health care providers, and patients highlight the need to examine the holistic properties of nursing care. The Holistic Caring Inventory is a theoretically sound, valid, and reliable tool; however, it does not comprehensively address attributes that have come to define holistic nursing care, necessitating the development of a more current instrument to measure the elements of a holistic perspective in nursing care. The development of a current and more comprehensive measure of holistic nursing care may be critical in demonstrating the importance of a holistic approach to patient care that reflects the principles of relationship-based care, shared decision-making, authentic presence, and pattern recognition.

Keywords: holistic; conceptual/theoretical descriptors/identifiers; holistic care; holistic nursing; methodological innovations/instrument development; common themes

Holistic care has long been a defining attribute become necessary to quantify and substantiate holis- of nursing practice. Indeed, as Lang and Krejci tic nursing care to policy-makers, legislators, nurses, (1991) attest, “the phrase ‘holistic nursing’ is redun- and consumers. The purpose of this article is to dant. Whether nursing is defined by the [ANA] identify instruments that describe and quantify Social Policy Statement, Nightingale (1860/1992), holistic nursing care from the patient’s perspective or Rogers (1990), it is holistic or it is not nursing” and to explore those attributes of holistic care that (p. 16). From the earliest years of its formal history, may be lacking in existing instruments and that may nursing has favored a holistic approach in the care contribute to the development of a current and com- of patients, and such an approach has become more prehensive measure. important over time. With the publication of the Institute of Medicine’s (IOM, 2010) recommenda- Evolution of Holistic Nursing Care tions for the future of nursing and passage of the Patient Protection and Affordable Care Act (PPACA, The defining characteristics of holistic nursing 2010), nursing continues to broaden its practice care have evolved subtly over time. Nightingale (1860/ boundaries and more clearly articulate its perspec- 1992) considered illness as a state of disequilibrium tive, as the profession takes on greater responsibility in delivering high-quality patient care. In view of patients’ expressed preference for relationship-centered care, the high cost and growing fragmentation Author’s Note: Please address correspondence to Elizabeth Kinchen, PhD, RN, AHN-BC, Florida Atlantic University, 777 of health care delivery, and the struggle Glades Rd., Boca Raton, FL 33431, USA; e-mail: ekinche1@ to secure reimbursement for holistic practices, it has fau.edu.

Downloaded from jhn.sagepub.com at SAGE Publications on June 18, 2015 2 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX and healing as a natural process, strongly influenced and healing activities. A relationship that focuses on by a patient’s environment. By the turn of the 20th the patient’s experience of health and illness and century, this view had expanded to public health nurs- seeks to understand and honor the patient’s priori- ing, and although the term “holistic” was not yet used, ties in healing is an integral component of holistic nurses continued to promote health using a holistic nursing care (Dossey, 2009). Patient preference for approach—considering the effects of the physical, a relationship-centered approach to care is well- social, and community environments in patients’ lives documented (Luxford, Safran, & Delblanco, 2011; (Boschma, 1994). In the latter half of the century, McQueen, 2000; Miller & Apker, 2002; Tresolini, nursing theorists (Orlando, 1961; Peplau, 1952) had 1994; Watson & Foster, 2003); such an approach is begun to include concepts from psychology and soci- characterized by a conscious and intentional shift ology relating to the dynamics of interpersonal rela- toward caring and healing relationships and modali- tionships in care theories, and models emerged that ties, communication patterns, and authentic rela- were individualized, comprehensive, and patient- and tionships (Moore & Hanson, 2009). These qualities relationship-centered. Social consciousness, plane- mirror a holistic focus in care delivery, and patient tary stewardship, dissatisfaction with the effects of preference for care that honors these qualities is an industrialization and technology, and interest in new important impetus for exploring its advantages. age and Eastern philosophies and spiritual beliefs contributed to the conceptualization of a holistic focus in health and healing. Such a focus embraced Comprehensive Care the unity of mankind and the interconnectedness of Comprehensive care is aimed at coordinating mind, body, and spirit. The counterculture of the and improving how care is delivered, with the goal of 1960s was especially influential in bringing what are improving health outcomes and quality of life. now termed alternative and complementary modali- Advances in medical science have enabled peo- ties such as meditation, yoga, acupuncture, herbal ple to live longer; this increase in longevity has remedies, and relaxation techniques into the public brought with it an increase in the number of indi- discourse. The concepts of patient- and relationship- viduals living with chronic illnesses (Volland, centered care, the interconnectedness of the mind Schraeder, Shelton, & Hess, 2013). Chronic illness and body, and the healing potential of alternative presents significant challenges in care management, therapies began to define a holistic framework for as the needs of patients with chronic conditions are nursing (Boschma, 1994). often complex, and may be addressed by numerous The American Holistic Nursing Association health care providers. Patient care is therefore often (AHNA) was formally established in 1981 as a venue fragmented, incomplete, and inefficient, leading to for the exploration, discussion, and dissemination of unnecessary hospitalizations, increased use of emer- holistic ideas and the American Nurses Association gency facilities, polypharmacy, and conflicting plans (ANA), recognizing holistic nursing’s unique approach of care (Volland et al., 2013). to health and healing, granted specialty status to the Holistic nursing care is comprehensive in that it AHNA in 2006. The AHNA (2012) describes a holistic takes into account the patient’s physical, emotional, nurse as one who takes a holistic (mind-body-spirit- social, spiritual, and psychological well-being and emotion) approach to the practice of traditional nurs- includes the consideration and use of complemen- ing, an approach that is based on a body of knowledge, tary and alternative modalities (CAMs), if desired or sophisticated skill sets, standards of practice, and a indicated. And although the use of CAM is not nec- philosophy of living and being that is grounded in car- essarily a defining attribute of holistic nursing care, ing, relationship, and interconnectedness. such therapies may be proposed and utilized by patients as avenues to healing and as adjuncts to The Importance of Holistic more conventional medical treatment. Nursing Care CAMs Patient Preference Public interest in CAMs has increased in recent The nurse’s relationship with patients consti- years. The American Hospital Association, in part- tutes the foundation for therapeutic interactions nership with the Samueli Institute (2011), reports

Downloaded from jhn.sagepub.com at SAGE Publications on June 18, 2015 Holistic Nursing Care / Kinchen 3 that holistic therapies used in conjunction with or as nurses to be allowed to practice to the fullest extent alternatives to conventional medical therapies (phar- of their education, to achieve higher levels of educa- maceuticals, surgery, etc.) are becoming more popu- tion, to be recognized as full partners with physi- lar across the United States. Their most recent cians and other health care professionals in reforming survey indicates that approximately 38% of all health care delivery, and to expand research and Americans use therapies such as meditation, mas- improve data collection, in order to identify best sage, yoga, and natural products (including herbal practices and ensure better quality health care. preparations) for a variety of chronic conditions, In addition, the question of legitimation of holis- including musculoskeletal pain, migraines, arthritis, tic nursing care and practices for purposes of reim- anxiety and depression, and high cholesterol. In bursement and policy creation has highlighted the addition, and largely in response to consumer need for studies that show the effectiveness and demand, hospitals offer these therapies to patients value of holistic nursing care and for correlating as part of their care. In fact, many patients (43%) holistic nursing care with positive health outcomes; report that they prefer holistic therapies over con- gauging the degree to which nurses use a holistic, ventional medical approaches, more than 10% say patient-centered, and comprehensive approach that they prefer to see a health care practitioner who should constitute the first step in this endeavor. would consider using them, and 69% pay for complementary or alternative therapies out-of-pocket Working Definition of Holistic (Samueli Institute, 2011, p. 6). According to the National Center for Nursing Care Complementary and Alternative Medicine (NCCAM, For the purposes of this article, and in alignment 2011), most patients who seek complementary or with the AHNA’s (Mariano, 2009) statement of core alternative therapies pay for them out-of-pocket, as values of holistic nursing, holistic nursing care may many of these therapies are not reimbursable by be comprehensively defined as developing a relation- insurance. This means that access to CAM therapies ship with patients in which the nurse honors and and providers is often limited to those who have dis- promotes consideration of the wholeness of persons, posable income. The NCCAM cites the lack of sci- authentic presence, and facilitation of healing, while entific evidence for the cost-effectiveness and incorporating the physical, emotional, spiritual, efficacy of such treatments in treating and relieving social, and psychological aspects of the patient’s the effects of stress-related and chronic health con- existence in supporting, guiding, and assisting ditions as a factor in the insurance industry’s reluc- patients in gaining self-knowledge and in co-creating tance to underwrite such practices. a plan of care. This definition may serve as a starting point in defining the critical attributes of holistic Policy, Recognition, and nursing care, in order to identify and evaluate pos- Reimbursement sible limitations in existing measures. With passage of the PPACA (2010) and publication of the IOM’s (2010) report, nurses are slated to Instruments Measuring Holistic take on an expanded role in health care delivery in Nursing Care the near future. Nurse practitioners, in particular, will be instrumental in filling the gap in primary care As the focus of nursing care has shifted to practitioner availability engendered by the increas- patient- and relationship-centered care and patient ing specialization of physician practice and increased preference for a holistic approach in health care access to health care made possible by the provisions delivery has become more evident, defining and of the PPACA. The IOM (2010) cites nurses’ “stead- measuring holistic nursing care has become more fast commitment to patient care, improved safety important. However, measures designed specifically and quality, and better outcomes” as making them to evaluate the holistic quality of nurse-patient ideally suited to delivering high-quality, safe, and encounters are somewhat scarce. equitable patient care, and for assuming a leadership There are many scales designed to measure caring role in redesigning the health care system (pp. xi- in nurse-patient interactions (Watson, 2009), as well xii). Key recommendations from the report call for as scales designed to measure individual components

Downloaded from jhn.sagepub.com at SAGE Publications on June 18, 2015 4 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX of holistic care, such as physical and emotional well- spiritual domains of nursing care in four subscales: being (Giasson & Bouchard, 1998), spiritual needs Physical Caring, Interpretive Caring, Spiritual (Galek, Flannely, Vane, & Galek, 2005), empathy Caring, and Sensitive Caring. (Mercer & Reynolds, 2002), relationship (Simmons, The HCI is a 40-item, 4-point Likert-type scale Roberge, Kendrick, & Richards, 1995), personal sup- scored by summating responses, with the total score port (Brandt & Weinert, 1981), and compassion divided by the number of items to produce a defini- (Burnell & Agan, 2013). And although these meas- tive score between 1 and 4. A score of 1 indicates ures certainly incorporate some features of holistic that the patient does not feel cared for, and a score care, they do not adequately or completely operation- of 4 indicates that caring is evident to the patient. alize all the components of a holistic focus in nursing Reliability and validity of the HCI were established care. early in its development and use; content validity In an effort to locate existing measures of holis- was established by two content specialists. The HCI tic nursing care, a literature search was initiated. was determined to have a content validity index of Keywords holistic nursing, holistic caring, measures, 1.00 (a perfect score). In addition, a pilot study of 30 instruments, and scales were used. The majority of hospitalized medical patients confirmed item clarity instruments accessed (n = 63) were concerned with and a sixth- to seventh-grade reading comprehen- measuring some aspect of holistic nursing care, such sion level (Latham, 1988). as spirituality, coping, self-transcendence, stress Discriminate validity was assessed by simultane- relief, self-help, life attitude, psychosocial factors, ous administration of Kiesler’s (1987) Message Impact serenity, comfort, meaning and quality of life, sexu- Inventory, which measures the interpersonal impact ality, transcultural considerations, or empathy. Two of others, and concurrent validity was evaluated using instruments were tentatively identified as compre- the Interpretive Caring Subscale in the HCI and the hensive measures of holistic nursing care. One was Supportive Behavior Checklist (Gardner & Wheeler, a scale designed to measure holistic nursing compe- 1987). Low correlations supported discriminate valid- tence (Takase & Teraoka, 2011), but it did not ity of the HCI with the Message Impact Inventory’s address or define holistic attributes of nursing care; Hostile subscale (.20, p < .01), and with its submis- rather, it explored “general aptitude and competen- sive scale (.16, p < .05), and moderate correlations cies” in providing nursing care. The other (Williams, (.39, p < .001) were found between the Interpretive 1998) was the Holistic Caring Inventory (HCI), Caring Subscale in the HCI and the Supportive which will be discussed below. Behavior Checklist. Reliability of the HCI has been established in several studies of predominantly hospi- The HCI talized medical and oncology patients (Latham, 1996; Williams, 1997a, 1997b, 1998) and was found to be The most comprehensive holistic nursing care strong, with scores for all four subscales of .89 (inter- instrument to date is Latham’s (1988) HCI, and, pretive caring), .87 to .91 (spiritual caring), and .90 while it addresses some aspects of holistic nursing (physical and sensitive caring). care, it was developed in the late 1980s, and does not completely reflect those attributes that have Analysis of subscale content. Physical caring in the come to define a holistic approach in promoting HCI refers to caring for the patient’s physical condi- health and healing. The HCI was developed to tion or needs and is addressed by exploring discussion measure patients’ perceptions of nurse caring—spe- of and adjustment to physical problems. Although the cifically, humanistic caring from a holistic nursing HCI does consider how physical conditions may perspective (Latham, 1996). According to Howard affect other areas of the patient’s life, it does not (1975), humanistic caring encompasses the princi- explicitly consider how patterning of life events and ples of inherent worth, individuality, the considera- choices may be influencing a physical condition. tion of the entirety of a person’s existence rather Interpretive caring items in the HCI reflect the than a specific problem, freedom of choice, status nurse’s ability to recognize and consider patient feel- equality, shared decision-making, empathy, and ings in providing information and care; these items emotional connectedness. Using Howard’s (1975) are mainly centered on the acknowledgment of the theoretical model as a guide, holistic nurse caring in patient’s feelings and on how the patient’s condition the HCI explores the social, physical, mental, and may affect personal relationships and circumstances

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Table 1. Holistic Attributes Not Addressed in the HCI

Authentic Presence Pattern Recognition Shared Decision-Making Spirituality

Therapeutic use of self Patterning of life events Empowerment Importance for healing and choices Relationship Self-healing Complementary and Purpose and meaning alternative therapies in life Nurse as instrument of Self-care Therapeutic partnering Peace healing Intentionality Self-knowledge Facilitation of healing Wellness/well-being in the patient’s life, such as work. These items do these elements of holistic nursing care should be not, however, address the pursuit of conscious considered. awareness of the interconnectedness of mind and body, the exploration of pattern recognition in emotion-laden life events, or how exploring feelings may Holistic Attributes Not Addressed assist in gaining self-knowledge. in the HCI Spiritual caring in the HCI covers such topics as the nurse’s ability to recognize and assist the patient Dimensions or attributes of holistic nursing care in obtaining spiritual guidance, but items do not not comprehensively addressed in the HCI are pre- explore the nurse’s discussion of a patient’s belief sented in Table 1. system or his or her search for meaning in life. Items relating to sensitive caring involve percep- Authentic Presence tion of the nurse’s behavior—listening, showing concern, discussing, and reacting to patient feelings. Authentic presence is a vital component of holis- These items do address empathic or compassionate tic nursing care and is integral to the nurse’s relation- support for the patient, but do not explore the ship with patients (Burkhardt & Nagai-Jacobson, patient’s perception of the nurse’s intentional pres- 2009). The nurse’s presence in the relationship is ence or support for patient input in care decisions, defined by the ability to be consciously focused on especially when those decisions do not follow a con- the patient and to bring the qualities of support, ventional treatment plan. empathy, and compassion to interactions (McKivergin, Although the HCI is considered here as a com- 2009). prehensive holistic measure and its reliability and validity are not called into question, the holistic Support. Support is a key component of holistic attributes it measures are limited to aspects of the nursing care. Support for care decisions, in life physical, emotional, and spiritual dimensions of choices, and in catastrophic events are common nursing care, without considering those features threads in holistic nursing care. In fact, a supportive that holistic nursing has come to be defined by— environment (both social and emotional) has been namely, authentic presence, the facilitation of pat- shown to reduce the incidence of health problems, tern recognition in the development of self-knowledge and it has been noted that the number of supporters, and self-care, and shared decision-making, includ- as well as the quality of that support, are important ing the use of alternative and complementary modal- factors in promoting healing (Stuart-Shor & Wells- ities as therapeutic tools (Mariano, 2009). In Federman, 2009, p. 185). addition, the items in the HCI addressing the nurse’s Examples of questions designed to elicit the per- consideration of spiritual factors influencing health ception of support by the nurse might include: “The and healing do not consider those aspects of spirit- nurse asks if there is someone who loves and cares ual meaning not necessarily associated with reli- about me” and “When I am upset, the nurse asks if gious entities, such as the search for peace, meaning, I have someone I can talk to.” Although the HCI and purpose in life. Therefore, development of a does address the nurse as a source of support in the more current, comprehensive tool that includes Sensitive Caring subscale, elements such as these

Downloaded from jhn.sagepub.com at SAGE Publications on June 18, 2015 6 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX could expand that dimension to explore other, more Pattern Recognition personal sources of support for patients. The recognition of patterns in life events and situations is aimed at bringing self-knowledge to the Empathy. Included in the consideration of authentic level of conscious awareness. Newman (1986) presence is the concept of empathy. Mercer and describes the responsibility of the nurse as not to Reynolds (2002) propose that the aims of empathy in make sick people well or to prevent disease, but to therapeutic relationships are “to initiate supportive assist patients in recognizing the healing power that interpersonal communication in order to understand is within them, by facilitating self-knowledge through the perceptions and needs of the patient, to empower the identification of life patterns. The nurse uses self the patient to learn or cope more effectively, and to as a therapeutic tool to assist patients in recognizing reduce or resolve a problem” (p. S9). LaMonica how life circumstances and decisions may be affect- (1981) defines empathy similarly as “a central focus ing their capacity for healing. An important compo- and feeling with and in the client’s world” (p. 398). nent in self-knowledge is the ability to be gentle with Interestingly, LaMonica (1981) postulates that all oneself in the discovery of flaws and setbacks. elements of the concept must be present for empa- In holistic nursing practice, self-compassion is thy to be perceived and further that the “empathic seen as a necessary antecedent to healing and to process” is hierarchical, with each step building developing a healing relationship with others. Neff upon the previous one. In other words, the helper (2003) defines self-compassion as being open to must perceive need in another, communicate the one’s own suffering, caring for self, and taking a perception of need, and convey understanding to the nonjudgmental attitude toward one’s own inadequa- person expressing the need (p. 399). cies and failures. Neff (2003) makes the distinction, Mercer and Reynolds (2002) support this notion, however, between self-centeredness (selfishness) observing that “it is the patient’s perception of the and self-compassion, emphasizing that self-centere- helping relationship that determines the effective- dness may involve a ruminative, or even obsessive, ness of empathy” (p. S10). Stuart-Shor and Wells- preoccupation with one’s own troubles to the exclu- Federman (2009) also highlight the importance of sion of others, whereas self-compassion entails empathy as an effective coping technique and as a “acknowledging that suffering, failure and inadequa- critical component in holistic communication by cies are part of the human condition, and that all maintaining that the ability to consider another’s people—oneself included—are worthy of compas- perspective promotes caring through mindful reflec- sion” (p. 224). tion and active listening (p. 187). Items designed to Examples of items that might assess the nurse’s address empathic interactions with the nurse might attention to a patient’s level of self-compassion include “the nurse shows concern for what matters could include “the nurse explores how I feel about most to me” and “the nurse talks to me about what my own flaws and inadequacies” and “the nurse is stressful in my life.” helps me to see my failings as part of the human condition.” The exploration of a patient’s ability to Compassion. Compassion is a concept closely related be “self-compassionate” would be an important com- to empathy, as it requires, according to Roach (2007), ponent in a measure of holistic nursing care, as it “immersion into the pain, brokenness, fear, and might assist in identification of pattern formation anguish of another, even when that person is a and level of self-knowledge. stranger” (p. 37). Similarly, Burnell and Agan (2013) define compassion as “a sympathetic consciousness Shared Decision-Making of another’s distress, with the intention of alleviating it” (p. 181). The HCI does contain items that address The promotion of shared decision-making in the nurse’s attention to patients’ feelings; however, health care choices is another area that has come to questions that more directly address the nurse’s abil- define holistic nursing care (Mariano, 2009). Shared ity to enter into the patient’s situation and provide decision-making involves the patient as the authority hope, kindness, and understanding might with on his or her own health, and the nurse as a partner advantage be included in a comprehensive measure and facilitator in the understanding of options, of holistic nursing care. effects, and implications of therapeutic choices,

Downloaded from jhn.sagepub.com at SAGE Publications on June 18, 2015 Holistic Nursing Care / Kinchen 7 including the use of CAMs, if desired. Mariano Exploring patients’ need for and success in describes this involvement as “a process of engage- achieving inner peace and relaxation, however, ment versus compliance” (p. 54) and stresses that should be included in a measure of holistic care, holistic nursing care honors the belief that patients especially items addressing general health, positive have an inherent capacity for self-healing and a right well-being and self-control, and such feelings as sat- to self-direction, qualities that the nurse supports isfaction with life and overall happiness—certainly and respects. subjects of interest in considering health and heal- Items designed to capture the nurse’s attention ing from a holistic perspective. Items such as “the to shared decision-making might include “the nurse nurse explores my need for guidance from a power is interested in what I think is causing or influencing outside myself” and “the nurse asks if I have a quiet my condition” and “the nurse supports my health place to meditate or reflect” may point to ways of care decisions, even if they differ from what others attending to spiritual beliefs and of providing a holis- think is best for me.” tic approach to spiritual care in a way that is not wholly dependent on religious reference (Galek Spirituality et al., 2005). Spirituality is something of a “special case” in terms of evaluating the meaning or quality of life in Conclusion the facilitation of healing. It is, in essence, what “arises from a search for meaning” (Mariano, 2009, A holistic focus has traditionally defined nurs- p. 49). And as Dossey (1984) contends, “at some ing’s approach to patient care, and this approach has level, health … is a ground state, a state of whole- become more important over time. The expansion of ness which excludes nothing. It is lodged ‘in spirit’; nursing’s responsibility in delivering comprehensive it is subsumed by spirit. And the knowledge of health care, the recognition of the importance of relation- is made possible by spiritual awareness” (p. 181). ship-centered care, and the need for evidence-based Spirituality, with its inescapably religious con- legitimation of holistic nursing care and practices to notations, can be an emotional and somewhat con- insurance companies, policy-makers, health care tentious area in nursing care, as spiritual beliefs are providers, and patients highlight the need to exam- intensely personal, difficult to express at times, and ine the holistic properties of nursing care. The HCI viewed as potentially controversial; indeed, its nature is a theoretically sound, valid, and reliable tool; how- is such that meeting (or even attempting to assess) ever, it does not comprehensively address attributes spiritual needs in clinical environments is often that have come to define holistic nursing care, avoided (Galek et al., 2005). However, as Burkhardt necessitating the development of a more current and Nagai-Jacobson (2009) point out, “the work of instrument to measure the elements of a holistic healing requires recognition of the spiritual dimen- perspective in nursing care. The development of a sion of each person, including the healer, and an current and more comprehensive measure of holistic awareness that spirituality permeates every encoun- nursing care may be critical in demonstrating the ter” (p. 623). importance of a holistic approach to patient care The question of how to comprehensively assess that reflects the principles of relationship-based and attend to spiritual needs in patient care has long care, shared decision making, authentic presence, plagued nurses, in part because of the difficulty in and pattern recognition. defining such an intangible and elusive concept. Galek et al (2005) propose that the inherent difficulty in dealing with spirituality arises because “the References human spirit is not easy to define and, perhaps, American Holistic Nurses Association. (2012). What is holis- there is an argument that … the human spirit is tic nursing? Retrieved from http://www.ahna.org/AboutUs/ indescribable.” Furthermore, they acknowledge the WhatisHolisticNursing/tabid/1165/Default.aspx challenge in understanding and investigating a “phe- Boschma, G. (1994). The meaning of holism in nursing: nomenon that is both transcendent and beyond the Historical shifts in holistic nursing ideas. Public Health sphere of the finite mind” (p. 62). Nursing, 11(5), 324-330.

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